THE RESEARCH CHALLENGE
It can be easy to rush to judgment about the mothers involved in the MAiN project. However, like most of the tragic stories that have come from the opioid epidemic in the U.S., there is no single path to addiction and no easy villain at which to point a finger.
Rachel Mayo, professor in Clemson’s public health sciences department, admits that even she had to check her emotions as a mother at the door when she was first introduced to the work Hudson was doing in 2012 when she was brought on board to inform Hudson’s work with research. Any preconceptions she had of these mothers were quickly removed when she saw the similarities across their stories.
“As soon as I dug in, I realized they were just people who fell victim to the usual story of opioid addiction,” Mayo says. “They had an accident or were injured, they were prescribed opioids, they became addicted to a highly addictive drug and then they got pregnant.”
Mothers involved in the MAiN program are typically in treatment for their own dependency, and quitting cold turkey is not advised for pregnant mothers due to the toll withdrawal takes on the mother’s body and the baby in utero. Mayo, who has previously specialized in research involving women’s health and cancer prevention, said she was immediately attracted to the project not only from a women’s health standpoint, but also because of the growing nationwide prevalence of neonatal abstinence syndrome.
The National Institute on Drug Abuse estimates that 32,000 babies born in the U.S. developed neonatal abstinence syndrome in 2014, which was a fivefold increase since 2004. That’s a baby born every 15 minutes who will experience opioid withdrawal, and opioid use has yet to plateau in the U.S.
The “big picture” was clear enough to Mayo, but the project needed specific, accurate data to determine the effectiveness of Hudson’s approach in the Upstate South Carolina population. With the added gray area that comes along with a stigmatized population such as substance-dependent mothers, the challenge in data collection became that much greater.
“Mothers are understandably afraid to self-identify for fear that their child will be taken from them, so infants would wind up in NICUs too late, or they were leaving hospitals before withdrawal symptoms occurred and coming back through emergency rooms,” Mayo says. “We needed good, solid numbers, and there were a variety of factors that made that tricky.”
Mayo, along with the Clemson team and Hudson’s staff, began pulling data from years of medical records related to pregnancies. To account for those mothers and babies who might have fallen through statistical cracks, they looked back also at emergency room readmission data 30 to 60 days after birth in order to paint as accurate a picture of the data as possible.
Clemson researchers began to also analyze the protocols developed by Hudson’s team, including the standardized plan of care for mothers in the program as well as the data they were capturing from mothers and infants. These tweaks would go on to improve future data collection and analysis of the MAiN protocol.
Mayo says that while the hunt for accurate, reliable data was difficult, it was plain to see that Hudson’s approach was working for infants. The approach was also becoming more reliable as the physicians and pharmacologists zeroed in on a methadone wean that was effective for each infant. Since 2012, 90 percent of mothers whose newborns qualified for early treatment have chosen the MAiN protocol.
Those infants have avoided devastating weight loss that comes from burning calories in withdrawal and the disorganized feeding skills that emerge from not eating or having time to bond with their mother. They have avoided both the special protocols to address bleeding caused by diaper rash and a need for long-term physical therapy required to help the infant finally relax after the trauma of withdrawal. They have avoided pain.
“For me, the most exciting thing was seeing that babies receiving this treatment did the same or better than those that went to NICUs,” Mayo says. “This approach would be extremely successful if it were just limited to medical outcomes, but there are many more benefits.”

A LARGER IMPACT
Lori Dickes, associate professor and director of Clemson’s master of public administration program, analyzes the project’s broader economic impact. She says that a mom and baby “graduating” from the program at a successful three-month checkup can have a big downstream effect.
“Creating a system of care in which mothers feel less judged and more supported is better for all of us,” Dickes says. “The hundreds of mothers and children who’ve benefited from this program will have a more positive view of health care, and they’ll be more likely to make their health a priority; the longer-term spillover effects are substantive.”
The evidence supporting the immediate and lasting positive impacts for mom and baby grow with every infant born in the MAiN program, as does the evidence that the program is simply smart for hospitals to employ.
Infants who don’t have to be admitted to NICUs free up space for other newborns in need and ease the workload of NICU doctors, nurses and staff. Infants in the program are also far less likely to be evaluated in emergency rooms for withdrawal symptoms after discharge from the hospital. Almost 90 percent of infants in the program are covered by Medicaid, so savings are ultimately passed on to taxpayers; the research team estimates that hospitals save approximately $89,400 per birth.
“According to research, the biggest proverbial bang for society’s buck is with children or infants,” Dickes says. “If we can get babies and children off to a healthy start, then everybody wins. This project is showing that from an economic standpoint, the approach developed by the MAiN program is good for our communities and not just individuals.”
Even though the data was promising, the team wanted to provide even more backup for the program’s effectiveness by conducting a pilot program at another Upstate hospital. Hudson says that even in a smaller hospital with less resources, outcomes in the pilot program were the same or better for mothers and infants.
The pilot program also revealed ways in which expansion to other hospitals could be made easier for hospital staff. A half-day training session was expanded to a six-hour, web-based training module that addressed feedback gathered during the pilot. Training includes video instruction and training materials provided directly by members of the MAiN team.
Thanks to the pilot and the data collected, the Department of Health and Human Services provided more funding through 2022 that will allow the MAiN program to expand to 10 hospitals across the state. Mayo says MAiN data compared to state and national data helped make the case for expansion.
“We’ve shown the program to be effective at Prisma Health and during the pilot program, so we look forward to seeing how the program is implemented across the state,” Mayo says. “The opioid epidemic is a nationwide issue, so we’d like to come together with even more health care systems and academics to spread the positive results and lessons learned in this program as it is refined in the coming years.”
The first children who graduated from the MAiN model of care are now in their early teens, so researchers will also begin looking at the long-term outcomes they’ve experienced. The team is particularly interested in any developmental issues — or lack thereof — that might be tied to participation in the program compared to long-term outcomes in other children.
The program has come a long way since 2003, and it can all be traced to one person’s well-developed sense of empathy. Hudson never anticipated that a method she decided to experiment with out of frustration might be expanded across the state and considered across the nation. She also never anticipated being as affected by the relationships she’s established with moms in the program.
She says one of her primary goals when working with them is to reinforce good behavior. Sometimes that’s as easy as Hudson taking the time to tell a mom that she’s proud of the choices that she’s making for herself and her soon-to-be-born child. Last year, that simple phrase elicited a response that reminded Hudson again that she was on the right track.
“All I said to the mother was, ‘I’m proud of you,’ and she just broke down in tears,” Hudson says. “She told me that no one had ever told her that before. It broke my heart. Every mother deserves to hear that, just like every mother and child deserve to have a positive birth experience. It can be tough for anyone, and it shouldn’t be any tougher for them.”